Provider Demographics
NPI:1609340785
Name:FERRAEZ, WILL TANNER (SLP)
Entity Type:Individual
Prefix:
First Name:WILL
Middle Name:TANNER
Last Name:FERRAEZ
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 VILLAGE LOOP
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-1635
Mailing Address - Country:US
Mailing Address - Phone:662-295-4992
Mailing Address - Fax:
Practice Address - Street 1:521 WINIFRED RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6392
Practice Address - Country:US
Practice Address - Phone:662-289-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08376235Z00000X
MSS4294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist